Hospital Infection Warning Sent Out to 12,000 Seattle Children’s Hospital Patients

About 12,000 families have been warned that children and young adults who were patients at Seattle Children’s Hospital may have been exposed to blood borne pathogens, because equipment may not have been properly sterilized between patients. 

The hospital began contacting families of former patients after discovering that established procedures for sterilizing certain equipment was not followed. The hospital is notifying anyone who had a child undergo a procedure at the hospital between June 2010 to August 20, 2015, urging them to have their children tested for diseases like hepatitis C and HIV, as well as other potential infections.

The problem was discovered at Seattle Children’s Bellevue Clinic and Surgery Center, but may have affected surgical equipment at other clinics run by the hospital. The details of the sterilization errors have not yet been disclosed.

“During a recent inspection at Seattle Children’s Bellevue Clinic and Surgery Center, we learned that although surgical instruments went through our sterilization process, some of the required cleaning steps were not always followed correctly,” the hospital said in its warning (PDF). “While the risk of infection to patients is very low, we don’t know the exact risk to each patient at this time.”

The hospital’s statement indicates that the incident is still under investigation and it is unknown why some sterilization steps were not followed. Hospital officials have said that all equipment that may have been affected has been properly sterilized at this point.

The statement notes that only patients at the Bellevue, Mill Creek and Everett clinics are believed to have been affected. Patients at the main hospital were not included in the warning.

The U.S. Centers for Disease Control and Prevention (CDC) has categorized the incident as a Catebory B infection control breach, meaning that the agency believes there is a very low risk of infection. To date, hundreds of children have been tested and no infections have been linked to the improperly sterilized equipment.

Parents with questions about the Seattle warning can call Seattle Children’s Call Center at 1-855-855-8460 or visit the website at www.seattlechildrens.org/safety.

This latest hospital infection warning comes after a number of hospital infection outbreaks were reported earlier this year, including an outbreak of carbapenem-resistant enterobacteriaceae (CRE) that was revealed in February by UCLA’s Ronald Reagan Medical Center. The outbreak was linked to problems cleaning duodenoscopes between endoscopic procedures, causing at least seven infections with the “super bug”, including two deaths.

Those duodenoscope infections have been linked to problems with the “reprocessing” instructions provided by the manufacturer for cleaning the devices. FDA reviewers determined that the instructions sent out at the time were inadequate and that even if the recommended steps were followed to clean endoscopic retrograde cholangiopancreatography (ERCP) endoscopes, flaws in the design may allow them to become easily contaminated.

The FDA has since issued new cleaning instructions and guidelines for the duodenoscopes.

Several duodenoscope infection lawsuits have already been filed  against Olympus over the infections linked to the UCLA outbreak. The complaints allege that design problems that make the scopes especially difficult to clean, placing patients at higher risk of contracting illness.